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Qureshi AI, Bhatti IA, Gillani SA, Beall J, Cassarly CN, Gajewski B, Martin RH, Suarez JI, Kwok CS. Prevalence, trends, and outcomes of cerebral infarction in patients with aneurysmal subarachnoid hemorrhage in the USA. J Neuroimaging 2024. [PMID: 39223763 DOI: 10.1111/jon.13229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND AND PURPOSE Cerebral infarction remains an important cause of death or disability in patients with aneurysmal subarachnoid hemorrhage (SAH). The prevalence, trends, and outcomes of cerebral infarction in patients with aneurysmal SAH at a national level are not known. METHODS We identified the proportion of patients who develop cerebral infarction (ascertained using validated methodology) among patients with aneurysmal SAH and annual trends using the Nationwide Inpatient Sample (NIS) from 2016 to 2021. We analyzed the effect of cerebral infarction on in-hospital mortality, routine discharge without palliative care (based on discharge disposition), poor outcome defined by the NIS SAH outcome measure, and length and costs of hospitalization after adjusting for potential confounders. RESULTS A total of 35,305 (53.6%) patients developed cerebral infarction among 65,840 patients with aneurysmal SAH over a 6-year period. There was a trend toward an increase in the proportion of patients who developed cerebral infarction from 51.5% in 2016 to 56.1% in 2021 (p trend p<.001). Routine discharge was significantly lower (30.5% vs. 37.8%, odds ratio [OR] 0.82, 95% confidence interval [CI] 0.75-0.89, p<.001), and poor outcome defined by NIS-SAH outcome measure was significantly higher among patients with cerebral infarction compared with those without cerebral infarction (67.4% vs. 59.3%, OR 1.29, 95% CI 1.18-1.40, p<.001). There was no difference in in-hospital mortality (13.0% vs. 13.6%, OR 0.94, 95% CI 0.85-1.05, p = .30). The length of stay (median 18 days [interquartile range [IQR] 13-25] vs. 14 days [IQR 9-20]), coefficient 3.04, 95% CI 2.44-3.52 and hospitalization cost (median $96,823 vs. $71,311, coefficient 22,320, 95% CI 20,053-24,587) were significantly higher among patients who developed cerebral infarction compared with those who did not develop cerebral infarction. CONCLUSIONS Cerebral infarction was seen in 54% of the patients with a trend toward an increase in the affected proportion of patients with aneurysmal SAH. Patients with cerebral infarction had higher rates of adverse outcomes and required higher resources during hospitalization.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Ibrahim A Bhatti
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Syed A Gillani
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christy N Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Byron Gajewski
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Renee H Martin
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chun Shing Kwok
- Department of Cardiology, Leighton Hospital, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK, Crewe, UK
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Burns JD, Lerner DP. Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage: Still More Questions Than Answers. Neurology 2024; 103:e209690. [PMID: 38950290 DOI: 10.1212/wnl.0000000000209690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Affiliation(s)
- Joseph D Burns
- From the Department of Neurology (J.D.B.), Lahey Hospital and Medical Center, Burlington, and UMass Chan Medical School, Worcester, MA; and Department of Neurology (D.P.L.), Brookdale Hospital and Medical Center and SUNY Downstate, Brooklyn, NY
| | - David P Lerner
- From the Department of Neurology (J.D.B.), Lahey Hospital and Medical Center, Burlington, and UMass Chan Medical School, Worcester, MA; and Department of Neurology (D.P.L.), Brookdale Hospital and Medical Center and SUNY Downstate, Brooklyn, NY
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Yang C, Zhao Z, Yang B, Wang K, Zhu G, Miao H. Sex Differences in Outcome of Aneurysmal Subarachnoid Hemorrhage and Its Relation to Postoperative Cerebral Ischemia. Neurocrit Care 2024:10.1007/s12028-024-02028-9. [PMID: 38954369 DOI: 10.1007/s12028-024-02028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/31/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Whether there is a sex difference in the outcome of aneurysmal subarachnoid hemorrhage (aSAH) remains controversial, and clarifying the role of women in postoperative cerebral ischemic events can help us to understand its relationship with poor prognosis. Therefore, the purpose of this study was to elucidate the relationship between the three aspects of sex differences, postoperative cerebral ischemia, and poor prognosis after aSAH. METHODS A total of 472 patients admitted within 72 h after aSAH between January 2018 and December 2022 were included. We systematically analyzed the characteristics of sex differences in aSAH and explored the relationship between delayed cerebral ischemia (DCI), surgery-related cerebral infarction (SRCI), and poor prognosis (modified Rankin Scale > 2). RESULTS Compared with women, men were in worse condition and had more intracerebral hematoma (p = 0.001) on admission, whereas women were older (p < 0.001) and had more multiple aneurysms (p = 0.002). During hospitalization, men were more likely to experience emergency intubation (p = 0.036) and tracheotomy (p = 0.013). Women achieved functional independence at discharge at a similar rate to men (p = 0.394). Among postoperative complications, the incidence of DCI (22% vs. 12%, p = 0.01) and urinary tract infection (p = 0.022) was significantly higher in women. After adjusting for age, multivariable regression analysis showed that hypertension (odds ratio [OR] 2.139, 95% confidence interval [CI] 1.027-4.457), preoperative rerupture (OR 12.240, 95% CI 1.491-100.458), pulmonary infection (OR 2.297, 95% CI 1.070-4.930), external ventricular drainage placement (OR 4.382, 95% CI 1.550-12.390), bacteremia (OR 14.943, 95% CI 1.412-158.117), SRCI (OR 8.588, 95% CI 4.092-18.023), venous thrombosis (OR 5.283, 95% CI 1.859-15.013), higher modified Fisher grades (p = 0.003), and Hunt-Hess grades (p = 0.035) were associated with poor prognosis, whereas DCI (OR 1.394, 95% CI 0.591-3.292) was not an independent risk factor for poor prognosis. The proportion of patients who fully recovered from cerebral ischemia was higher in the DCI group (p < 0.001) compared with the SRCI group, and more patients were discharged with modified Rankin Scale > 2 in the SRCI group (p = 0.005). CONCLUSIONS Women have a higher incidence of DCI, but there is no sex difference in outcomes after aSAH, and poor prognosis is associated with worse admission condition and perioperative complications. SRCI is a strong independent risk factor for poor prognosis, whereas DCI is not.
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Affiliation(s)
- Cheng Yang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Zenan Zhao
- Department of Neurosurgery, Chongqing Western Hospital, Chongqing, 400052, China
| | - Biao Yang
- Department of Neurosurgery, Dazu Hospital of Chongqing Medical University, Chongqing, 402360, China
| | - Kaishan Wang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Hongping Miao
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, China.
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Al-Salihi MM, Gillani SA, Saha R, Abd Elazim A, Al-Jebur MS, Al-Salihi Y, Ayyad A, Nattanmai P, Siddiq F, Gomez CR, Qureshi AI. Clinical Characteristics as Predictors of Early and Delayed Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage Patients: A Meta-Analysis of 4527 Cases. World Neurosurg 2024:S1878-8750(24)01018-0. [PMID: 38906475 DOI: 10.1016/j.wneu.2024.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Predictors of delayed cerebral infarction (DCI) and early cerebral infraction (ECI) among aneurysmal subarachnoid hemorrhage (aSAH) patients remain unclear. We aimed to systematically review and synthesize the literature on predictors of ECI and DCI among aSAH patients. METHODS We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases comprehensively from inception through January 2024 for observational cohort studies examining predictors of DCI or ECI following aneurysmal SAH. Studies were screened, reviewed, and meta-analyzed, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines. The data were pooled as Odds ratios (OR) with 95% confidence intervals using Review Manager 5.4 software. Methodologic quality was assessed with the Newcastle-Ottawa Scale. RESULTS Our meta-analysis included 12 moderate to high-quality cohort studies comprising 4527 patients. Regarding DCI predictors, Higher severity scores (OR = 1.49, 95% confidence interval [1.12, 1.97], P = 0.005) and high Fisher scores (OR = 2.23, 95% confidence interval [1.28, 3.89], P = 0.005) on presentation were significantly associated with an increased risk of DCI. Also, the female sex and the presence of vasospasm were significantly associated with an increased risk of DCI (OR = 3.04, 95% confidence interval [1.35, 6.88], P = 0.007). In contrast, preexisting hypertension (P = 0.94), aneurysm treatment (P = 0.14), and location (P = 0.16) did not reliably predict DCI risk. Regarding ECI, the pooled analysis demonstrated no significant associations between sex (P = 0.51), pre-existing hypertension (P = 0.63), severity (P = 0.51), or anterior aneurysm location versus posterior (P = 0.86) and the occurrence of ECI. CONCLUSION Female sex, admission disease severity, presence of vasospasm and Fisher grading can predict DCI risk post-aSAH. Significant knowledge gaps exist for ECI predictors. Further large standardized cohorts are warranted to guide prognosis and interventions.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
| | - Syed A Gillani
- Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA; Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Ram Saha
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ahmed Abd Elazim
- Department of Neurology, University of South Dakota, Sioux Falls, South Dakota, USA
| | | | | | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | | | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA; Department of Neurology, University of Missouri, Columbia, Missouri, USA
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Du W, Yang J, Lou Y, You J. Hypothermia on the first day of ICU admission leads to increased in-hospital mortality in patients with subarachnoid hemorrhage. Sci Rep 2024; 14:9730. [PMID: 38678080 PMCID: PMC11055887 DOI: 10.1038/s41598-024-60657-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/25/2024] [Indexed: 04/29/2024] Open
Abstract
The relationship between early spontaneous hypothermia and adverse clinical outcomes in patients with subarachnoid hemorrhage (SAH) has not been paid much attention. We designed this retrospective cohort study to determine this relationship by analyzing the association between the lowest body temperature (T-lowest) on the first day of ICU admission and in-hospital mortality. In this study, 550 participants with non-traumatic SAH were chosen from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Multivariate Cox regression analysis showed that T-lowest was nonlinearity correlated with in-hospital mortality (HR = 0.72, 95% CI: 0.59-0.86, p < 0.001). We divided the T-lowest into quartile groups. In comparison to reference group Q1 (31.30-36.06 ℃), group Q3 (36.56-36.72 ℃) had a 50% lower risk of death in the hospital (HR: 0.5, 95% CI: 0.28-0.87, p = 0.014). We further confirmed the curve-like relationship between T-lowest and in-hospital mortality using restricted cubic splines. The mortality is lowest when the T-lowest is close to 36.5 °C, and the risk of death is increased when the temperature is lower or higher than that. Our study demonstrates that in-hospital mortality is associated with T-lowest. Patients with non-traumatic SAH are at increased risk of death if their body temperature on the first day of ICU admission is too low.
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Affiliation(s)
- Wenyuan Du
- Department of Neurology, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, Hebei, China.
| | - Jingmian Yang
- Department of Neurology, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, Hebei, China
| | - Yanfang Lou
- Department of Neurology, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, Hebei, China
| | - Jiahua You
- Department of Neurology, Shijiazhuang Traditional Chinese Medicine Hospital, Shijiazhuang, Hebei, China
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Krawchuk LJ, Sharrock MF. Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury. Semin Neurol 2023; 43:699-711. [PMID: 37802120 DOI: 10.1055/s-0043-1775790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.
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Affiliation(s)
- Lindsey J Krawchuk
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew F Sharrock
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Wipplinger C, Cattaneo A, Wipplinger TM, Lamllari K, Semmler F, Geske C, Messinger J, Nickl V, Beez A, Ernestus RI, Pham M, Westermaier T, Weiland J, Stetter C, Kunze E. Serum concentration-guided intravenous magnesium sulfate administration for neuroprotection in patients with aneurysmal subarachnoid hemorrhage: a retrospective evaluation of a 12-year single-center experience. Neurosurg Rev 2023; 46:256. [PMID: 37751032 PMCID: PMC10522732 DOI: 10.1007/s10143-023-02159-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023]
Abstract
Delayed cerebral infarction (DCI) is a major cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). The benefits of magnesium sulfate as an alternative treatment are controversial, and most previous studies examined its benefits only as adjunctive treatment to traditional nimodipine. We retrospectively analyzed aSAH patients records with magnesium sulfate between 2010 and 2021. We aimed for a serum magnesium concentration of 2-2.5 mmol/l between post-hemorrhage days 3 and 12. The patients were separated in three groups based on average serum magnesium concentration (magnesium >2 mmol/l, reduced magnesium 1.1-1.9 mmol/l, and no magnesium). Additionally, we assessed delayed cerebral infarction (DCI) and clinical outcome at follow-up, using the modified Rankin Scale (mRS), categorized in favorable (0-3) and unfavorable outcome (4-5). In this analysis, 548 patients were included. Hereof, radiological evidence of DCI could be found in 23.0% (n = 126) of patients. DCI rates were lower if patients' average serum magnesium was higher than 2 mmol/l (magnesium 18.8%, n = 85; reduced magnesium 38.3%, n = 23; no magnesium 51.4%, n = 18; p < 0.001). Also, at the last follow-up, patients in the group with a higher serum magnesium concentration had better outcome (favorable outcome: magnesium 64.7%, n = 293; reduced magnesium 50.0%, n = 30; no magnesium 34.3%, n = 12; p < 0.001). This 12-year study reveals the value of serum concentration-guided magnesium administration in aSAH patients. Our findings demonstrate the safety and efficacy when titrated to a serum concentration of 2-2.5 mmol/l. We observed higher rates of delayed cerebral infarction and unfavorable outcomes in patients with serum concentrations below 2 mmol/l.
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Affiliation(s)
- C Wipplinger
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany.
| | - A Cattaneo
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - T M Wipplinger
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - K Lamllari
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - F Semmler
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - C Geske
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - J Messinger
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - V Nickl
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - A Beez
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - R-I Ernestus
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - M Pham
- Department of Neuroradiology, University Hospital of Würzburg, Würzburg, Germany
| | - T Westermaier
- Department of Neurosurgery, Helios Amper-Klinikum Dachau, Dachau, Germany
| | - J Weiland
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - C Stetter
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - E Kunze
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
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Ozono I, Ikawa F, Hidaka T, Matsuda S, Oku S, Horie N, Date I, Suzuki M, Kobata H, Murayama Y, Sato A, Kato Y, Sano H. Different Risk Factors Between Cerebral Infarction and Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 173:e487-e497. [PMID: 36841530 DOI: 10.1016/j.wneu.2023.02.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVE Cerebral infarction due to cerebral vasospasm (IVS) after aneurysmal subarachnoid hemorrhage is associated with poor outcomes and symptomatic cerebral vasospasm (SVS). However, the difference of risk factors between SVS and IVS was unclear to date. In this study, we aimed to elucidate the risk factors for SVS and IVS based on the registry study. METHODS The modified World Federation of Neurosurgical Societies scale study comprises 1863 cases. Patients with aneurysmal subarachnoid hemorrhage who underwent radical treatment within 72 hours with a premorbid modified Rankin Scale score 0-2 as the inclusion criteria were retrospectively examined. The risk factors for SVS and IVS were analyzed using multivariable logistic regression analysis. RESULTS Among them, 1090 patients who met the inclusion criteria were divided into 2 groups according to SVS and IVS; 273 (25%) patients with SVS and 92 (8.4%) with IVS. Age was not a risk factor for SVS, but for IVS, and Fisher scale was a risk factor for SVS, but not for IVS. CONCLUSIONS The prevalence of IVS was not associated with the Fisher scale but with older age, suggesting possible factors other than SVS. Different associated factors between SVS and IVS were confirmed in this study.
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Affiliation(s)
- Iori Ozono
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan; Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Toshikazu Hidaka
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Shingo Matsuda
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Shinnichiro Oku
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michiyasu Suzuki
- Department of Advanced ThermoNeuroBiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Osaka, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Sato
- Department of Rehabilitation, Gotanda Rehabilitation Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hirotoshi Sano
- Department of Neurosurgery, Shinkawabashi Hospital, Kawasaki, Japan
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Garg A, Elmashala A, Roeder H, Ortega-Gutierrez S. Endovascular coiling versus neurosurgical clipping for treatment of ruptured and unruptured intracranial aneurysms during pregnancy and postpartum period. J Neurointerv Surg 2023; 15:310-314. [PMID: 35508381 DOI: 10.1136/neurintsurg-2022-018705] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/19/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Selection of appropriate surgical strategy for the treatment of intracranial aneurysms (IA) during pregnancy requires careful consideration of the potential risks to the mother and fetus. However, limited data guide treatment decisions in these patients. We compared the safety profiles of endovascular coiling (EC) and neurosurgical clipping (NC) performed for the treatment of ruptured and unruptured IA during pregnancy and the postpartum period. METHODS Pregnancy-related or postpartum hospitalizations undergoing surgical intervention for IA were identified from the Nationwide Readmissions Database 2016-2018. Safety outcomes included periprocedural complications, in-hospital mortality, discharge disposition, and 30-day non-elective readmissions. RESULTS There were 348 pregnancy-related or postpartum hospitalizations that met the study inclusion criteria (mean±SD age 31.8±5.9 years). Among 168 patients treated for ruptured aneurysms, 115 (68.5%) underwent EC and 53 (31.5%) underwent NC; whereas among 180 patients treated for unruptured aneurysms, 140 (77.8%) underwent EC and 40 (22.2%) underwent NC. There were no statistically significant differences in the baseline characteristics between patients undergoing EC versus NC for either ruptured or unruptured aneurysm groups. The outcomes were statistically comparable between EC and NC for both ruptured and unruptured IA, except for a lower incidence of ischemic stroke in patients undergoing EC for ruptured aneurysms (OR 0.12, 95% CI 0.02 to 0.84). CONCLUSIONS Most pregnant and postpartum patients are treated with EC for both ruptured and unruptured IA. For treatment of ruptured IA, EC is independently associated with a lower risk of perioperative ischemic stroke, but other in-hospital complications and mortality are comparable between EC and NC.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Amjad Elmashala
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Hannah Roeder
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Departments of Neurology, Neurosurgery, and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Hu P, Yan T, Li Y, Guo G, Gao X, Su Z, Du S, Jin R, Tao J, Yuan Y, Yang X, Xiao B, Wu M, Ye M, Lv S, Liao J, Chen Q, Zhu X. Effect of Surgical Clipping versus Endovascular Coiling on the Incidence of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Observational Cohort Study with Propensity Score Matching. World Neurosurg 2023; 172:e378-e388. [PMID: 36657714 DOI: 10.1016/j.wneu.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The effect of surgical clipping (SC) and endovascular coiling (EC) on the incidence of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) has always been a controversial topic. Hence, it is necessary to reanalyze the effects of the 2 surgical methods on DCI, which determines the choice of the most favorable method for patients who are suitable for both surgical modalities. METHODS A multicenter retrospective observational cohort study was performed to evaluate all consecutive patients with aSAH admitted to 5 medical centers in China between April 2019 and June 2021. Univariable and multivariable analyses were used to confirm risk factors of DCI after aSAH. A 1:1 propensity score matching model was generated in the EC and SC groups to reduce the influence of all confounding factors on DCI. RESULTS A total of 412 patients were included, and 115 patients (27.9%) developed DCI. After propensity score matching for controlling demographic information, past medical history, admission clinical status, aneurysm characteristics, and inflammatory factors associated with DCI, 133 patients with SC and 133 patients with EC treatment were matched. The results of the matched cohorts indicate a significantly lower incidence of DCI when patients received EC than SC (31.9% vs. 20%; adjusted odds ratio, 1.87; 95% confidence interval, 1.08-3.29; P = 0.027). CONCLUSIONS The study found that the patients who received SC treatment had a higher incidence of DCI than did those who received EC and suggested that ruptured intracerebral aneurysm is preferentially coiled rather than clipped if the aneurysm is suitable for both surgical modalities.
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Affiliation(s)
- Ping Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China; Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, Jiangxi, China; Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, Jiangxi, China; Institute of Neuroscience, Nanchang University, Nanchang, Jiangxi, China
| | - Tengfeng Yan
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China; Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, Jiangxi, China; Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, Jiangxi, China; Institute of Neuroscience, Nanchang University, Nanchang, Jiangxi, China
| | - Yuntao Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Geng Guo
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xu Gao
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Zhongzhou Su
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Senlin Du
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ruiyun Jin
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jiarong Tao
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ye Yuan
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xinlei Yang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Bing Xiao
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Miaojing Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Minhua Ye
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Shigang Lv
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianmin Liao
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xingen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China; Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, Jiangxi, China; Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, Jiangxi, China; Institute of Neuroscience, Nanchang University, Nanchang, Jiangxi, China.
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11
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Snider S, Albano L, Gagliardi F, Comai S, Roncelli F, De Domenico P, Pompeo E, Panni P, Bens N, Calvi MR, Mortini P, Ruban A. Substantially elevated serum glutamate and CSF GOT-1 levels associated with cerebral ischemia and poor neurological outcomes in subarachnoid hemorrhage patients. Sci Rep 2023; 13:5246. [PMID: 37002262 PMCID: PMC10066256 DOI: 10.1038/s41598-023-32302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/25/2023] [Indexed: 04/03/2023] Open
Abstract
Brain injury and cerebral vasospasm during the 14 days after the subarachnoid hemorrhage (SAH) are considered the leading causes of poor outcomes. The primary injury induces a cascade of events, including increased intracranial pressure, cerebral vasospasm and ischemia, glutamate excitotoxicity, and neuronal cell death. The objective of this study was to monitor the time course of glutamate, and associated enzymes, such as glutamate-oxaloacetate transaminase (GOT1), glutamate-pyruvate transaminase (GPT) in cerebrospinal fluid (CSF) and serum, shortly after SAH, and to assess their prognostic value. A total of 74 participants participated in this study: 45 participants with SAH and 29 controls. Serum and CSF were sampled up to 14 days after SAH. SAH participants' clinical and neurological status were assessed at hospitalization, at discharge from the hospital, and 3 months after SAH. Furthermore, a logistic regression analysis was carried out to evaluate the ability of GOT1 and glutamate levels to predict neurological outcomes. Our results demonstrated consistently elevated serum and CSF glutamate levels after SAH. Furthermore, serum glutamate level was significantly higher in patients with cerebral ischemia and poor neurological outcome. CSF GOT1 was significantly higher in patients with uncontrolled intracranial hypertension and cerebral ischemia post-SAH, and independently predicted poor neurological outcomes.
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Affiliation(s)
- Silvia Snider
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Comai
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy
| | - Francesca Roncelli
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pierfrancesco De Domenico
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Pompeo
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pietro Panni
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Nicole Bens
- Behavioral Neuroscience, Human Movement Science, Mathematics, Pre-Medicine, Northeastern University COS, Boston, MA, USA
| | - Maria Rosa Calvi
- Department of Neurocritical Care, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angela Ruban
- Sackler Faculty of Medicine, Steyer School of Health Professions, Tel Aviv University, P.O. Box 39040, 6997801, Tel-Aviv, Israel.
- Sagol School of Neuroscience, Tel-Aviv University, P.O. Box 39040, 6997801, Tel-Aviv, Israel.
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12
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Florez WA, Martinez-Perez R, Deora H, Joaquim AF, García-Ballestas E, Quiñones-Ossa GA, Rivas-Palacios C, Agrawal A, Serrato SA, Jabbour P, Moscote-Salazar LR. An update of predictors of cerebral infarction after aneurysmal subarachnoid hemorrhage: systematic review and meta-analysis. J Neurosurg Sci 2023; 67:1-9. [PMID: 36112119 DOI: 10.23736/s0390-5616.22.05445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Evidence about predictors of poor outcomes such as cerebral infarction (CI) after aneurysmal subarachnoid hemorrhage (aSAH) has not been fully elucidated. EVIDENCE ACQUISITION We performed a systematic review and meta-analysis on studies with adults with aSAH considering RCT and non-RCT, prospective, and retrospective cohort studies describing clinical, imaging as well as angiographic studies in patients with aSAH. EVIDENCE SYNTHESIS After reviewing the complete text, 11 studies were considered eligible, out of which four were ruled out. Degree of clinical severity was the most predictive factor with a higher degree at the presentation on different severity scales being associated with a statistically significant increasing the risk of suffering a CI following aSAH (OR 2.49 [95% CI 1.38-4.49] P=0.0003). Aneurysm size increased the risk of CI (OR 1.49 [95% CI 1.20-1.85] P=0.0003; I2=4%). In six studies analyzed, it was found that an important factor for the subsequent development of CI is vasospasm (OR 7.62 [2.19, 26.54], P=0.0001). CONCLUSIONS The development of vasospasm is a risk factor for CI development after aSAH. In our review, three factors were associated with an increased risk of CI: clinical severity at presentation, vasospasm, and aneurysm size. The major limitation of this meta-analysis is that included studies were conducted retrospectively or were post hoc analyses of a prospective trial.
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Affiliation(s)
- William A Florez
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.,Division of Neurosurgery, Institute of Neurosciences, Austral University of Chile, Valdivia, Chile
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Andrei F Joaquim
- Department of Neurosurgery. University of Campinas (UNICAMP), São Paulo, Brazil
| | - Ezequiel García-Ballestas
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Gabriel A Quiñones-Ossa
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia - .,Faculty of Medicine, El Bosque University, Bogotá, Colombia
| | - Claudio Rivas-Palacios
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Luis R Moscote-Salazar
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
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13
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Chalet FX, Briasoulis O, Manalastas EJ, Talbot DA, Thompson JC, Macdonald RL. Clinical Burden of Angiographic Vasospasm and Its Complications After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review. Neurol Ther 2023; 12:371-390. [PMID: 36609962 PMCID: PMC10043150 DOI: 10.1007/s40120-022-00436-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Angiographic vasospasm (VSP), the narrowing of intracranial arteries, is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and often results in delayed cerebral ischemia (DCI) and cerebral infarction. The objective of this systematic review was to summarize the clinical burden of angiographic VSP and its related complications (DCI and cerebral infarction) after aSAH. METHODS Systematic searches of MEDLINE, Embase, and the Cochrane Library were conducted (in January 2021) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies reporting clinical outcomes of angiographic VSP and its related complications after aSAH. Study outcomes included measures of functional status (modified Rankin Scale [mRS], Glasgow Outcome Scale [GOS], extended Glasgow Outcome Scale [GOS-E], modified Barthel Index, or the modified National Institutes of Health Stroke Scale), cognitive status (Montreal Cognitive Assessment or the Mini Mental State Exam), clinical events (rebleeding), and mortality. Study selection, data extraction, and qualitative analyses were conducted. RESULTS Of 5704 abstracts reviewed, 110 studies were selected: 20 comparative and 39 regression-based studies were included in the qualitative synthesis, 51 descriptive studies were excluded. Most studies (51) were observational and conducted in a single country (53). The occurrence of angiographic VSP and its related complications after aSAH resulted in significantly poorer functional outcomes in three of nine comparative and 11 of 13 regression-based studies, measured by the mRS, and in five of six comparative and eight of nine regression-based studies, measured by the GOS and GOS-E. Angiographic VSP and its related complications were significantly associated with poor cognitive status in all five regression-based studies. Numerically or significantly higher mortality rates in patients with versus those without angiographic VSP and its related complications were reported in five of ten comparative studies and in eight of nine regression-based studies. Six studies looked at specific VSP populations (e.g., by severity or timing of VSP). CONCLUSION Patients with angiographic VSP and its related complications often had poor functional, neurological, and cognitive outcomes and reduced odds of survival both in hospital and at follow-up. We estimate that angiographic VSP and its related complications, DCI and cerebral infarction, lead to an approximately threefold higher odds of poor functional and cognitive outcomes, and about a twofold increase in the odds of death.
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Affiliation(s)
| | - Orestis Briasoulis
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | | | - Darren A Talbot
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | | | - R Loch Macdonald
- Community Health Partners, Community Neurosciences Institute, Fresno, CA, 93701, USA
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14
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Simonato D, Gaugain S, Le Dorze M, Prisco L, Borchert RJ, Fuschi M, Patel J, Mebazaa A, Froelich S, Houdart E, Chousterman B, Labeyrie MA. Early Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage Is Associated with Prior Global Cerebral Hypoperfusion. World Neurosurg 2022; 168:e546-e554. [DOI: 10.1016/j.wneu.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
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15
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Solhpour A, Kumar S, Koch MJ, Doré S. Impact of blood component transfusions, tranexamic acid and fluids on subarachnoid hemorrhage outcomes. BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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16
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Protective effects of fraxin on cerebral ischemia-reperfusion injury by mediating neuroinflammation and oxidative stress through PPAR-γ/NF-κB pathway. Brain Res Bull 2022; 187:49-62. [PMID: 35772607 DOI: 10.1016/j.brainresbull.2022.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/24/2022] [Accepted: 06/25/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inflammation and oxidative stress are associated with the pathogenesis of cerebral ischemia-reperfusion (I/R) injury. Fraxin, one of the primary active ingredients of Cortex Fraxini, may have potent anti-inflammatory activity. This study intended to investigate the function and mechanism of fraxin in a middle cerebral artery occlusion (MCAO) model. METHODS A middle cerebral artery occlusion (MCAO) rat model was engineered. Both in-vivo and in-vitro models were dealt with Fraxin. The profiles of inflammation-concerned cytokines, proteins and oxidative stress factors were determined by RT-PCR, western blot, and enzyme-linked immunosorbent assay (ELISA), and neuronal apoptosis and reactive oxygen species (ROS) levels were measured. The neurological functions of rats were evaluated by Morris water maze and modified neurological severity scores (mNSS). RESULTS The data revealed that fraxin abated the OGD/R-mediated release of inflammatory and oxidative stress mediators, enhanced "M2″-like BV2 microglia polarization, and mitigated HT22 cell apoptosis. Mechanistically, fraxin boosted PPAR-γ expression, activated the Nrf2/HO-1 pathway, and suppressed NF-κB, IKK-β,p38 MAPK, ERK1/2 and Keap1 in a dose-dependent manner. Furthermore, attenuating PPAR-γ through pharmacological treatment with GW9662 (a PPAR-γ antagonist) mainly weakened the neuroprotective and anti-inflammatory functions of fraxin. CONCLUSION Fraxin could considerably ameliorate cerebral I/R damage by repressing oxidative stress, inflammatory response, and cell apoptosis through abrogating the PPARγ/ NF-κB pathway.
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17
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Su J, Huang H, Xin YJ, Liang YD, Wu XT, Yang XL, Liu XZ, He Z. Clinical Predictive Models for Delayed Cerebral Infarction After Ruptured Intracranial Aneurysm Clipping for Patients: A Retrospective Study. Front Surg 2022; 9:886237. [PMID: 35747431 PMCID: PMC9209644 DOI: 10.3389/fsurg.2022.886237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Objective A nomogram was developed in this work to predict the probability of delayed cerebral infarction (DCI) after ruptured intracranial aneurysms (RIA) clipping. Methods Clinical data of patients with intracranial aneurysm were obtained from the neurosurgery department of the First Affiliated Hospital of Chongqing Medical University from January 2016 to December 2020. A total of 419 patients receiving surgery of ruptured intracranial aneurysm clipping were included and a total of 37 patients with DCI were set as the observation group. The control group consisted of 382 patients without DCI. Risk factors of DCI were screened by univariate and multivariate logistic regression analysis and included in the nomogram. Results Univariate analysis showed that female (P = 0.009), small aneurysm (P = 0.031), intraoperative aneurysm rupture (P = 0.007) and cerebral vasospasm (P < 0.001) were risk factors for postoperative DCI while smoking history (P = 0.044) were protective factors for postoperative DCI. Multivariate Logistic regression analysis showed that small aneurysm (P = 0.002, OR = 3.332, 95%–7.104), intraoperative aneurysm rupture (P = 0.004, OR = 0.122, 95%-CI, 0.029–0.504)and cerebral vasospasm (P < 0.001, OR = 0.153, 95%-CI, 0.070–0.333) were independent risk factors of postoperative DCI. The calibration curve of the probability of occurrence showed that the nomogram was in good correspondence with the observed results with a C-index of 0.766 (95% CI, 0.684–0.848). Meanwhile, the Decision curve analysis (DCA) showed that the established predictive model had a good clinical net benefit. Conclusion The well-established nomogram is expected to be an effective tool to predict the occurrence of DCI after intracranial ruptured aneurysm and can be used to assist clinicians to develop more effective treatment strategies and improve the prognosis of patients.
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Affiliation(s)
- Jun Su
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Neurosurgery, The People’s Hospital of NanChuan, Chongqing, China
| | - Hao Huang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Neurosurgery, People’s Hospital of Chongqing Hechuan, Chongqing, China
| | - Yuan-jun Xin
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi-dan Liang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing, China
| | - Xin-tong Wu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-lin Yang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-zhu Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhaohui He
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Correspondence: Zhao-hui He
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18
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Winberg J, Holm I, Cederberg D, Rundgren M, Kronvall E, Marklund N. Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:255-266. [PMID: 35488171 PMCID: PMC9283139 DOI: 10.1007/s12028-022-01492-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/14/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH. METHODS Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3-15), and World Federation of Neurosurgical Societies scale 4 (range 1-5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h. RESULTS We analyzed 7,223 CMD samples over a median of 6 days (5-8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR < 30 for minor and LPR < 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region. CONCLUSIONS Active interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.
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Affiliation(s)
- Jakob Winberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Isabella Holm
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - David Cederberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Malin Rundgren
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Erik Kronvall
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, EA-blocket plan 4, Entrégatan 7, 222 42, Lund, Sweden.
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19
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Lukito PP, Lie H, Helsa K, July J. Heparin in the treatment of aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Focus 2022; 52:E9. [DOI: 10.3171/2021.12.focus21419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Cerebral vasospasm and the resulting infarction remain the most devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Limited treatment options are available, with nimodipine as the only approved prophylactic medication. In addition to its anticoagulant properties, heparin also has a pleiotropic and anti-inflammatory effect that could be beneficial in vasospasm. In this study, the authors sought to evaluate the efficacy and safety of heparin in the treatment of aSAH.
METHODS
The PubMed, EBSCOhost, Europe PMC, and Cochrane Central databases were searched to find studies including patients with aSAH who were treated with intravenous unfractionated heparin (UFH) after an aneurysm-securing procedure. Studies that did not include a comparison with UFH or low-molecular-weight heparin in deep vein thrombosis prophylactic doses were excluded. The primary outcome was cerebral vasospasm, and the secondary outcomes were cerebral infarction, clinical deterioration caused by delayed cerebral ischemia, bleeding complications, and thromboembolism complications.
RESULTS
Overall, 5 nonrandomized studies were included; 4 studies evaluated the safety and 3 studies evaluated the efficacy of intravenous heparin. From the analysis of 3 studies with a total of 895 patients, administration of intravenous UFH for > 48 hours was related to a significantly lower rate of cerebral infarction (OR 0.44, 95% CI 0.25–0.79). No significant association was found with other efficacy outcomes. Regarding cognitive outcome, one study found a significant improvement in Montreal Cognitive Assessment scores; however, the functional outcome as indicated by the modified Rankin Scale score was not improved by heparin administration. From the analysis of 4 studies with 1099 patients, no significant increases in bleeding and other complications were found.
CONCLUSIONS
Administration of intravenous UFH for more than 48 hours reduced the rate of cerebral infarction with a good safety profile. This result supports the ongoing clinical trial.
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Affiliation(s)
| | | | | | - Julius July
- Department of Neurosurgery, Neuroscience Centre Siloam Hospital, Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
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20
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Lin H, Wang H, Xu Y, Lin Z, Kang D, Zheng S, Yao P. Lower Body Temperature Independently Predicts Delayed Cerebral Infarction in the Elderly With Ruptured Intracranial Aneurysm. Front Neurol 2022; 12:763471. [PMID: 35046883 PMCID: PMC8761807 DOI: 10.3389/fneur.2021.763471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/03/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose: To assess the correlation between admission body temperature and delayed cerebral infarction in elderly patients with ruptured intracranial aneurysm (IA). Methods: Patients with ruptured IA diagnosed between 2012 and 2020 were retrospectively analyzed. Patients were divided into a non-infarction and an infarction group based on the presence of cerebral infarction after treatment. The demographic and clinical information of the patients was gathered. Outcomes at the 3-month follow-up were assessed using the modified Rankin Scale. Correlation between admission body temperature and cerebral infarction was assessed using Spearman's rank correlation coefficient. A receiver operating characteristic (ROC) curve was used to assess the specificity and sensitivity of admission body temperature to predict cerebral infarction. Results: A total of 426 patients (142 men and 284 women) with ruptured IA were enrolled. Elderly patients with cerebral infarction (12.4%) had a lower body temperature at admission (p < 0.001), higher prevalence of hypertension and diabetes (p = 0.051 and p = 0.092, respectively), and higher rate of poor outcomes (p < 0.001). Admission body temperature was independently associated with cerebral infarction (odds ratio [OR] = 5.469, p < 0.001); however, hypertension (OR = 0.542, p = 0.056), diabetes (OR = 0.750, p = 0.465), and aneurysm size (OR = 0.959, p = 0.060) showed no association. An inverse correlation between admission body temperature and the incidence of cerebral infarction was observed (Spearman's r =−0.195, p < 0.001). An admission body temperature of 36.6°C was able to distinguish infarction and non-infarction patients. The area under the ROC curve was 0.669 (specificity, 64.15%; sensitivity, 81.50%; p < 0.001). Conclusions: Lower body temperature at admission (≤36.6°C) is an independent predictor of delayed cerebral infarction in elderly patients who have undergone treatment for ruptured IA. Therefore, it could be a risk factor for adverse outcomes of IA.
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Affiliation(s)
- Hui Lin
- Department of Emergency, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Haojie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yawen Xu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhangya Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shufa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Peisen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:662-681. [PMID: 34940927 DOI: 10.1007/s12028-021-01372-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.
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Scullen T, Mathkour M, Wang A, Aysenne A, Dumont AS. Commentary: Systemic Immune-Inflammation Index Predicts Delayed Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 89:E304-E306. [PMID: 34676415 DOI: 10.1093/neuros/nyab370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/21/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Arthur Wang
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Aimee Aysenne
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA.,Department of Neurology, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
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Frase S, Steimer M, Selzner L, Kaiser S, Foit NA, Niesen WD, Schallner N. Temporal Expression Pattern of Hemoxygenase-1 Expression and Its Association with Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:279-291. [PMID: 34312792 PMCID: PMC8813853 DOI: 10.1007/s12028-021-01299-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 06/11/2021] [Indexed: 12/01/2022]
Abstract
Background Red blood cell-induced cerebral inflammation and toxicity has been shown to be attenuated by induction of the heme-catalyzing enzyme, hemoxygenase-1 (HO-1), in animal models of subarachnoid hemorrhage (SAH). Although inflammatory mechanisms leading to secondary neuronal injury in SAH are becoming increasingly well understood, markers of cerebral inflammation have so far not been implemented in clinical prediction models of SAH. Methods In this biomarker observational study, HO-1 messenger ribonucleic acid (mRNA) expression levels were determined in cerebrospinal fluid (CSF) and blood of 66 patients with aneurysmal SAH on days 1, 7, and 14 after the SAH event. HO-1 mRNA expression was determined via real time polymerase chain reaction (PCR), and relative expression changes were quantified in comparison with expression levels in nonhemorrhagic control CSF. Subarachnoid blood burden, as well as presence of vasospasm and delayed cerebral ischemia (DCI), were recorded. Short and long-term clinical outcomes were assessed using the Modified Rankin Scale at discharge and 1 year after the SAH event. Results CSF HO-1 expression levels showed a significant increase over the 14-day observation period (p < 0.001, F = 22.53) and correlated with intracranial hematoma burden (ρ = 0.349, p = 0.025). In multivariate analyses, CSF HO-1 expression levels did not reach significance as independent predictors of outcome. Vasospasm on computed tomographic angiography was associated with lower CSF HO-1 expression levels on day 7 after SAH (n = 53, p = 0.010), whereas patients with DCI showed higher CSF HO-1 expression levels on day 14 after SAH (n = 21, p = 0.009). Conclusions HO-1 expression in CSF in patients with SAH follows a distinct temporal induction pattern and is dependent on intracranial hematoma burden. CSF HO-1 expression was unable to predict functional outcome. Associations of early low HO-1 expression with vasospasm and late elevated HO-1 expression with DCI may point to detrimental effects of late HO-1 induction, warranting the need for further investigation in a larger study population.
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Affiliation(s)
- Sibylle Frase
- Department of Neurology and Neuroscience, Medical Center - University of Freiburg, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Matti Steimer
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Lisa Selzner
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Sandra Kaiser
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Niels Alexander Foit
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neuroscience, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Schallner
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
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Aldrich EF, Higashida R, Hmissi A, Le EJ, Macdonald RL, Marr A, Mayer SA, Roux S, Bruder N. Thick and diffuse cisternal clot independently predicts vasospasm-related morbidity and poor outcome after aneurysmal subarachnoid hemorrhage. J Neurosurg 2021; 134:1553-1561. [PMID: 32442971 DOI: 10.3171/2020.3.jns193400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. The presence of thick, diffuse subarachnoid blood may portend a worse clinical course and outcome, independently of other known prognostic factors such as age, aneurysm size, and initial clinical grade. METHODS In this post hoc analysis, patients with aSAH undergoing surgical clipping (n = 383) or endovascular coiling (n = 189) were pooled from the placebo arms of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS)-2 and CONSCIOUS-3 randomized, double-blind, placebo-controlled phase 3 studies, respectively. Patients without and with thick, diffuse SAH (≥ 4 mm thick and involving ≥ 3 basal cisterns) on admission CT scans were compared. Clot size was centrally adjudicated. All-cause mortality and vasospasm-related morbidity at 6 weeks and Glasgow Outcome Scale-Extended (GOSE) scores at 12 weeks after aSAH were assessed. The effect of the thick and diffuse cisternal aSAH on vasospasm-related morbidity and mortality, and on poor clinical outcome at 12 weeks, was evaluated using logistic regression models. RESULTS Overall, 294 patients (51.4%) had thick and diffuse aSAH. Compared to patients with less hemorrhage burden, these patients were older (median age 55 vs 50 years) and more often had World Federation of Neurosurgical Societies (WFNS) grade III-V SAH at admission (24.1% vs 16.5%). At 6 weeks, all-cause mortality and vasospasm-related morbidity occurred in 36.1% (95% CI 30.6%-41.8%) of patients with thick, diffuse SAH and in 14.7% (95% CI 10.8%-19.5%) of those without thick, diffuse SAH. Individual event rates were 7.5% versus 2.5% for all-cause death, 19.4% versus 6.8% for new cerebral infarct, 28.2% versus 9.4% for delayed ischemic neurological deficit, and 24.8% versus 10.8% for rescue therapy due to cerebral vasospasm, respectively. Poor clinical outcome (GOSE score ≥ 4) was observed in 32.7% (95% CI 27.3%-38.3%) and 16.2% (95% CI 12.1%-21.1%) of patients with and without thick, diffuse SAH, respectively. CONCLUSIONS In a large, centrally adjudicated population of patients with aSAH, WFNS grade at admission and thick, diffuse SAH independently predicted vasospasm-related morbidity and poor 12-week clinical outcome. Patients with thick, diffuse cisternal SAH may be an important cohort to target in future clinical trials of treatment for vasospasm.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Anthropometry
- Blood Coagulation
- Brain Damage, Chronic/etiology
- Clinical Trials, Phase III as Topic
- Computed Tomography Angiography
- Double-Blind Method
- Embolization, Therapeutic
- Endovascular Procedures
- Female
- Glasgow Outcome Scale
- Humans
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/diagnostic imaging
- Intracranial Aneurysm/surgery
- Intracranial Aneurysm/therapy
- Male
- Middle Aged
- Prognosis
- Randomized Controlled Trials as Topic
- Risk
- Subarachnoid Hemorrhage/blood
- Subarachnoid Hemorrhage/complications
- Subarachnoid Hemorrhage/diagnostic imaging
- Survival Analysis
- Treatment Outcome
- Vasospasm, Intracranial/blood
- Vasospasm, Intracranial/diagnostic imaging
- Vasospasm, Intracranial/etiology
- Young Adult
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Affiliation(s)
- E François Aldrich
- 1Department of Neurosurgery, University of Maryland, Baltimore, Maryland
| | - Randall Higashida
- 2Department of Neurointerventional Radiology, University of California San Francisco Medical Center, San Francisco, California
| | - Abdel Hmissi
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Elizabeth J Le
- 1Department of Neurosurgery, University of Maryland, Baltimore, Maryland
| | - R Loch Macdonald
- 4Department of Neurological Surgery, University of California San Francisco, Fresno, California
- 5Department of Surgery, University of Toronto, Ontario, Canada
| | - Angelina Marr
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Stephan A Mayer
- 6Department of Neurology, Henry Ford Neuroscience Institute, Wayne State School of Medicine, Detroit, Michigan; and
| | - Sébastien Roux
- 3Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Nicolas Bruder
- 7Department of Anesthesia and Critical Care, Hôpital de la Timone, Aix-Marseille Université, Marseille, France
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Chalard K, Szabo V, Pavillard F, Djanikian F, Dargazanli C, Molinari N, Manna F, Costalat V, Chanques G, Perrigault PF. Long-term outcome in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation. PLoS One 2021; 16:e0247942. [PMID: 33711023 PMCID: PMC7954305 DOI: 10.1371/journal.pone.0247942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients affected with aneurysmal subarachnoid hemorrhage (aSAH) often require intensive care, and then present distinctive outcome from less severe patients. We aimed to specify their long-term outcome and to identify factors associated with poor outcome. METHODS We conducted a retrospective study in a French university hospital intensive care unit. Patients with aSAH requiring mechanical ventilation hospitalized between 2010 and 2015 were included. At least one year after initial bleeding, survival and degree of disability were assessed using the modified Rankin Scale (mRS) via telephone interviews. A multivariable logistic regression analysis was performed to determine independent factors associated with poor outcome defined as mRS≥3. RESULTS Two-hundred thirty-six patients were included. Among them, 7 were lost to follow-up, and 229 were analyzed: 73 patients (32%) had a good outcome (mRS<3), and 156 (68%) had a poor outcome (mRS≥3). The estimated 1-year survival rate was 63%. One-hundred sixty-three patients patients (71%) suffered from early brain injuries (EBI), 33 (14%) from rebleeding, 80 (35%) from vasospasm and 63 (27%) from delayed cerebral ischemia (DCI). Multivariable logistic regression identified independent factors associated with poor outcome including delay between aSAH diagnosis and mRS assessment (OR, 0.96; 95% CI, 0.95-0.98; p<.0001), age (OR per 10 points, 1.57; 95% CI, 1.12-2.19; p = 0.008), WFNS V versus WFNS III (OR, 5.71; 95% CI 1.51-21.61; p = 0.004), subarachnoid rebleeding (OR, 6.47; 95% CI 1.16-36.06; p = 0.033), EBI (OR, 4.52; 95% CI 1.81-11.29; p = 0.001) and DCI (OR, 4.73; 95% CI, 1.66-13.49; p = 0.004). CONCLUSION Among aSAH patients requiring assisted ventilation, two-third of them survived at one year, and one-third showed good long-term outcome. As it appears as an independant factor associated with poor outcome, DCI shoud retain particular attention in future studies beyond angiographic vasospasm.
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Affiliation(s)
- Kevin Chalard
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, Inserm, Montpellier, France
- * E-mail:
| | - Vivien Szabo
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, Inserm, Montpellier, France
| | - Frederique Pavillard
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Flora Djanikian
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Federico Manna
- Epidemiology and Clinical Research Department, University Hospital of Montpellier, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - Gerald Chanques
- Department of Critical Care Medicine and Anesthesiology (DAR B), Saint Eloi University Hospital of Montpellier and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Pierre-Francois Perrigault
- Department of Critical Care Medicine and Anesthesiology (DAR C), Gui de Chauliac University Hospital of Montpellier, Montpellier, France
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Juif PE, Dingemanse J, Ufer M. Clinical Pharmacology of Clazosentan, a Selective Endothelin A Receptor Antagonist for the Prevention and Treatment of aSAH-Related Cerebral Vasospasm. Front Pharmacol 2021; 11:628956. [PMID: 33613288 PMCID: PMC7890197 DOI: 10.3389/fphar.2020.628956] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/30/2020] [Indexed: 11/16/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm and is associated with significant morbidity and mortality. It represents a major unmet medical need due to few treatment options with limited efficacy. The role of endothelin-1 (ET-1) and its receptor ETA in the pathogenesis of aSAH-induced vasospasm suggests antagonism of this receptor as promising asset for pharmacological treatment. Clazosentan is a potent ETA receptor antagonist for intravenous use currently under development for the prevention of aSAH-induced cerebral vasospasm. The pharmacokinetics of clazosentan are characterized by an intermediate clearance, a volume of distribution similar to that of the extracellular fluid volume, dose-proportional exposure, an elimination independent of drug-metabolizing enzymes, and a disposition mainly dependent on the hepatic uptake transporter organic anion transport polypeptide 1B1/1B3. In healthy subjects, clazosentan leads to an increase in ET-1 concentration and prevents the cardiac and renal effects mediated by infusion of ET-1. In patients, it significantly reduced the incidence of moderate or severe vasospasm as well as post-aSAH vasospasm-related morbidity and mortality. Clazosentan is well tolerated up to the expected therapeutic dose of 15 mg/h and, in aSAH patients, lung complications, hypotension, and anemia were adverse events more commonly reported following clazosentan than placebo. In summary, clazosentan has a pharmacokinetic, pharmacodynamic, and safety profile suitable to become a valuable asset in the armamentarium of therapeutic modalities to prevent aSAH-induced cerebral vasospasm.
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Affiliation(s)
- Pierre-Eric Juif
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
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Jang KM, Choi HH, Nam TK, Park YS, Kwon JT, Byun JS, Hwang D. The Effect of Locally Administered Fibrinolytic Drugs Following Aneurysmal Subarachnoid Hemorrhage : A Meta-Analysis with Eight Randomized Controlled Studies. J Korean Neurosurg Soc 2021; 64:207-216. [PMID: 33626858 PMCID: PMC7969038 DOI: 10.3340/jkns.2020.0154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/29/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Rapid dissolution of blood clots reduces vasospasm and hydrocephalus after subarachnoid hemorrhage (SAH), and locally administered fibrinolytic drugs (LAFDs) could facilitate the dissolution. However, the efficacy of LAFDs remains controversial. The aim of this meta-analysis was to determine the efficacy of LAFDs for vasospasm and hydrocephalus and in clinical outcomes.
Methods From PubMed, EMBASE, and Cochrane database, data were extracted by two authors. Meta-analysis was performed using a random effect model. Inclusion criteria were patients who had LAFDs with urokinase-type or recombinant tissue-plasminogen activator after SAH in comparison with medically untreated patients with fibrinolytic drugs. We only included randomized controlled trials (RCTs) in this analysis. The outcomes of interest were vasospasm, hydrocephalus, mortality, and 90-day unfavorable functional outcome.
Results Data from eight RCTs with 550 patients were included. Pooled-analysis revealed that the LAFDs were significantly associated with lower rates of vasospasm (LAFDs group vs. control group, 26.5% vs. 39.2%; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.32–0.73); hydrocephalus (LAFDs group vs. control group, 26.0% vs. 31.6%; OR, 0.54; 95% CI, 0.32–0.91); and mortality (LAFDs group vs. control group, 10.5% vs. 15.7%; OR, 0.58; 95% CI, 0.34–0.99). The proportion of 90-day unfavorable outcomes was lower in the LAFDs group (LAFDs group vs. control group, 32.7% vs. 43.5%; OR, 0.55; 95% CI, 0.37–0.80).
Conclusion This meta-analysis with eight RCTs indicated that LAFDs were significantly associated with lower rates of vasospasm and hydrocephalus after SAH. Thus, LAFDs could consequently reduce mortality and improve clinical outcome after SAH.
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Affiliation(s)
- Kyoung Min Jang
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Taek Kyun Nam
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yong Sook Park
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeong Taik Kwon
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jun Soo Byun
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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MFG-E8 attenuates inflammation in subarachnoid hemorrhage by driving microglial M2 polarization. Exp Neurol 2020; 336:113532. [PMID: 33245889 DOI: 10.1016/j.expneurol.2020.113532] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/05/2020] [Accepted: 11/19/2020] [Indexed: 11/21/2022]
Abstract
Increasing evidence suggests that microglial polarization plays an important role in the pathological processes of neuroinflammation following subarachnoid hemorrhage (SAH). Previous studies indicated that milk fat globule-epidermal growth factor-8 (MFG-E8) has potential anti-apoptotic and anti-inflammatory effects in cerebral ischemia. However, the effects of MFG-E8 on microglial polarization have not been evaluated after SAH. Therefore, the aim of this study was to explore the role of MFG-E8 in anti-inflammation, and its effects on microglial polarization following SAH. We established the SAH model via prechiasmatic cistern blood injection in mice. Double-immunofluorescence staining, western blotting and quantitative real-time polymerase chain reaction (q-PCR) were performed to investigate the expression and cellular distribution of MFG-E8. Two different dosages (1 and 5 μg) of recombinant human MFG-E8 (rhMFG-E8) were injected intracerebroventricularly (i.c.v.) at 1 h after SAH. Brain water content, neurological scores, beam-walking score, Fluoro-Jade C (FJC), and terminal deoxynucleotidyl transferase dUTP nick endlabeling staining (TUNEL) were measured at 24 h. Suppression of MFG-E8, integrin β3 and phosphorylation of STAT3 were achieved by specific siRNAs (500 pmol/5 μl) and the STAT3 inhibitor Stattic (5 μM). The potential signaling pathways and microglial polarization were measured by immunofluorescence labeling and western blotting. SAH induction increased the levels of inflammatory mediators and the proportion of M1 cells, and caused neuronal apoptosis in mice at 24 h. Treatment with rhMFG-E8 (5 μg) remarkably decreased brain edema, improved neurological functions, reduced the levels of proinflammatory factors, and promoted the microglial to shift to M2 phenotype. However, knockdown of MFG-E8 and integrin β3 via siRNA abolished the effects of MFG-E8 on anti-inflammation and M2 phenotype polarization. The STAT3 inhibitor Stattic further clarified the role of rhMFG-E8 in microglial polarization by regulating the protein levels of the integrin β3/SOCS3/STAT3 pathway. rhMFG-E8 inhibits neuronal inflammation by transformation the microglial phenotype toward M2 and its direct protective effect on neurons after SAH, which may be mediated by modulation of the integrin β3/SOCS3/STAT3 signaling pathway, highlighting rhMFG-E8 as a potential therapeutic target for the treatment of SAH patients.
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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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30
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Schupper AJ, Eagles ME, Neifert SN, Mocco J, Macdonald RL. Lessons from the CONSCIOUS-1 Study. J Clin Med 2020; 9:jcm9092970. [PMID: 32937959 PMCID: PMC7564635 DOI: 10.3390/jcm9092970] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.
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Affiliation(s)
- Alexander J. Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - Matthew E. Eagles
- Department of Clinical Neurosciences, Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, AB T3B 6A8, Canada;
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - R. Loch Macdonald
- Department of Neurological Surgery, UCSF Fresno, Fresno, CA 93701, USA
- Correspondence: ; Tel.: +1 (559) 459-3705
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Brami J, Chousterman B, Boulouis G, Dorze ML, Majlath M, Saint-Maurice JP, Civelli V, Froelich S, Houdart E, Labeyrie MA. Delayed Cerebral Infarction is Systematically Associated with a Cerebral Vasospasm of Large Intracranial Arteries. Neurosurgery 2020; 86:E175-E183. [PMID: 31501886 DOI: 10.1093/neuros/nyz340] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 06/16/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Whether delayed cerebral infarction (DCIn) after aneurysmal subarachnoid hemorrhage (aSAH) is driven by large artery vasospasm is still controversial. OBJECTIVE To study the association between DCIn and vasospasm by using quantitative assessment of vasospasm up to distal arteries with time and territorial-based correlation. METHODS Clinical and imaging data of 392 patients with aSAH treated at our center between 2012 and 2017 were reviewed. DCIn was defined as any cerebral infarction occurring within 3 to 21 d after ictus and not related to other specific cause. In patients with DCIn, vasospasm was assessed within 24 h around DCIn for each cerebral artery up to the end of the 2nd segments. DCIn and vasospasm analyses were blinded. RESULTS DCIn was found in 11% of patients (inter-rater k = 0.90, computed tomography (CT)-scan = 100%, follow-up MRI = 91%). Vasospasm was quantified in 258 artery territories including 66 with and 192 without DCIn (DSA = 93%, computed tomography angiography = 7%). Vasospasm was more severe in DCIn than in non-DCIn territories (60% [55-69] vs 20% [0-50], P < .001). Vasospasm was associated with DCIn in a "dose-dependent" manner (P for trend = .022). Every DCIn territory had a vasospasm ≥ 50%, including 39% only of distal artery segments. Only 9% of non-DCIn territories had vasospasm ≥ vasospasm in DCIn territories. CONCLUSION The necessary association between severe vasospasm and DCIn in our study brings additional arguments in favor of large artery vasospasm (especially of distal segments) as a major determinant of DCIn and a potential therapeutic target.
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Affiliation(s)
- Jonathan Brami
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Paris, France
| | - Benjamin Chousterman
- Department of Anesthesiology and Critical Care, Saint Louis Lariboisière University Hospitals, Assistance Publique - Hopitaux de Paris, Paris, France.,INSERM U942 MASCOT, Paris, France
| | - Grégoire Boulouis
- Department of Neuroradiology, Centre Hospitalier Saint-Anne, Paris, France
| | - Matthieu Le Dorze
- Department of Anesthesiology and Critical Care, Saint Louis Lariboisière University Hospitals, Assistance Publique - Hopitaux de Paris, Paris, France.,INSERM U942 MASCOT, Paris, France
| | - Melinda Majlath
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Paris, France
| | | | - Vittorio Civelli
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Paris, France
| | | | - Emmanuel Houdart
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Paris, France.,EA 7334 REMES (MAL, EH), Université Paris 7, Paris, France
| | - Marc-Antoine Labeyrie
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Paris, France.,EA 7334 REMES (MAL, EH), Université Paris 7, Paris, France
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Kanamaru H, Kawakita F, Asada R, Miura Y, Shiba M, Toma N, Suzuki H. Prognostic factors varying with age in patients with aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2020; 76:118-125. [PMID: 32299775 DOI: 10.1016/j.jocn.2020.04.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/04/2020] [Indexed: 11/27/2022]
Abstract
With the advent of an aging society, more elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) have been treated. We investigated if prognostic factors differ with age in aSAH patients. In a prospectively maintained aSAH database at multiple institutions from 2013 to 2016, 238 patients who underwent clipping or coiling for a ruptured aneurysm within 48 h of onset were divided into elderly (≥75 years; 57 patients) and non-elderly groups, or categorized into 4-age groups (<54, 55-64, 65-74, and ≥75 years). Prognostic factors and clinical characteristics were retrospectively analyzed. The elderly group had a higher incidence of pre-morbidities, co-morbidities, poor admission World Federation of Neurological Surgeons (WFNS) grades, modified Fisher grade 4, and resultantly 90-day poor outcomes (modified Rankin scale [mRS] 3-6). Multivariate logistic regression analyses revealed that independent determinants for poor outcomes were hypertension and modified Fisher grade 4 in the elderly group, and admission WFNS grades IV-V, systemic complications, non-procedural cerebral infarction and shunt-dependent chronic hydrocephalus in the non-elderly group. The 4-age group analyses showed that higher age group was more frequently associated with the prognostic factors. As higher age itself causes poor outcomes and more association of prognostic factors, prognostic factors in elderly patients may be rather limited.
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Affiliation(s)
- Hideki Kanamaru
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
| | - Fumihiro Kawakita
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Reona Asada
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Masato Shiba
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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- Members along with their affiliations listed in the Supplementary Material
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Mikhail M, Ayling OGS, Eagles ME, Ibrahim GM, Macdonald RL. Association between weekend admissions and mortality after aneurysmal subarachnoid hemorrhage: the "weekend effect" revisited. J Neurosurg 2020; 132:1167-1173. [PMID: 30925472 DOI: 10.3171/2019.1.jns183185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Higher mortality has been reported with weekend or after-hours patient admission across a wide range of surgical and medical specialties, a phenomenon termed the "weekend effect." The authors evaluated whether weekend admission contributed to death and long-term neurological outcome in patients following aneurysmal subarachnoid hemorrhage. METHODS A post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) study was conducted. Univariable and stepwise multivariable logistic regression analyses were performed to assess the associations between weekend admission and mortality and long-term neurological outcome. RESULTS Of 413 subjects included in the CONSCIOUS-1 study, 140 patients had been admitted during the weekend. A significant interaction was identified between weekend admission and neurological grade on presentation, suggesting that the outcomes of patients who had initially presented with a poor grade were disproportionately influenced by the weekend admission. On stepwise multivariable logistic regression in the subgroup of patients who had presented with a poor neurological grade (29 of 100 patients), admission on the weekend was found to be independently associated with death (OR 6.59, 95% CI 1.62-26.88, p = 0.009). Weekend admission was not associated with long-term neurological outcome. CONCLUSIONS Weekend admission was an independent risk factor for death within 12 weeks following aneurysmal subarachnoid hemorrhage in patients presenting with a poor neurological grade. Further work is required to identify and mitigate any mediating factors.
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Affiliation(s)
| | - Oliver G S Ayling
- 2Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia
| | | | - George M Ibrahim
- 4Division of Neurosurgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Ontario
| | - R Loch Macdonald
- 5Division of Neurosurgery, St. Michael's Hospital
- 6Labatt Family Centre of Excellence in Brain Injury and Trauma Research
- 7Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital; and
- 8Departments of Physiology and Surgery, University of Toronto, Ontario, Canada
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Ding C, Kang D, Chen P, Wang Z, Lin Y, Wang D, Lin Z, Gu J. Early stage neuroglobin level as a predictor of delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage. Brain Behav 2020; 10:e01547. [PMID: 32026621 PMCID: PMC7066341 DOI: 10.1002/brb3.1547] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/18/2019] [Accepted: 01/04/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The neuroglobin (Ngb) is well recognized as a potential biomarker for the hypoxic-ischemic brain injury. However, connection between Ngb and delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) is still unclear. OBJECTIVE To investigate the relationship between early stage Ngb level of aSAH patient and the occurrence of DCI. METHODS We evaluated 126 aSAH patients who were enrolled into a prospective observational cohort study. Serum Ngb level on days 1, 2, 3, 5, and 7 after aSAH were determined using a commercial enzyme-linked immunosorbent assay kit. The relationship between Ngb level and DCI was analyzed. RESULTS Forty-six (36.5%) aSAH patients experienced DCI. Patients with DCI had significantly higher Ngb levels than those without (p < .001). Multivariate model analysis revealed that day 3 Ngb level remained a significant factor after adjusting for World Federation of Neurosurgical Societies (WFNS) grade, modified Fisher grade, clipping and Ngb levels on days 1, 2, 5, and 7. Sensitivity, specificity, and Youden index of day 3 Ngb level for identifying DCI were derived as 73.9%, 72.5%, and 0.46, respectively, based on the best threshold of 8.4 ng/ml. Regardless in good-grade group or in poor-grade group, patients having day 3 Ngb level > 8.4 ng/ml has a significantly worse DCI survival rate than those having day 3 Ngb level <=8.4 ng/ml (p = .026 and .009, respectively). CONCLUSIONS Serum Ngb level was significantly elevated in DCI patients. Early stage aSAH Ngb level has the potential of being used as a novel DCI occurrence predictor, especially when Ngb level was combined with WFNS grade.
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Affiliation(s)
- Chenyu Ding
- Department of NeurosurgeryThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Dezhi Kang
- Department of NeurosurgeryThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Pengqiang Chen
- Department of NeurosurgeryThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Ziliang Wang
- Department of NeurosurgeryZhengzhou University People's HospitalHenan Provincial People's HospitalZhengzhouChina
| | - Yuanxiang Lin
- Department of NeurosurgeryThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Dengliang Wang
- Department of NeurosurgeryThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Zhangya Lin
- Department of NeurosurgeryThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
| | - Jianjun Gu
- Department of NeurosurgeryZhengzhou University People's HospitalHenan Provincial People's HospitalZhengzhouChina
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Which Protocol for Milrinone to Treat Cerebral Vasospasm Associated With Subarachnoid Hemorrhage? J Neurosurg Anesthesiol 2019; 31:323-329. [PMID: 30015694 DOI: 10.1097/ana.0000000000000527] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Milrinone has emerged as an option to treat delayed cerebral ischemia after subarachnoid hemorrhage. However, substantial variation exists in the administration of this drug. We retrospectively assessed the effectiveness of 2 protocols in patients with angiographically proven cerebral vasospasm. METHODS During 2 successive periods, milrinone was administered using either a combination of intra-arterial milrinone infusion followed by intravenous administration until day 14 after initial bleeding (IA+IV protocol), or a continuous intravenous milrinone infusion for at least 7 days (IV protocol). The primary endpoint was the reversion rate of vasospastic arterial segments following the first IA infusion of milrinone (IA+IV protocol) compared with the reversion rate during the first week of IV infusion (IV protocol). RESULTS There were 24 and 77 consecutive patients in IA+IV and IV protocols, respectively. The reversion rate was comparable between the 2 protocols: 71% (95% confidence interval [CI], 59%-83%) in the IA+IV protocol versus 64% (95% CI, 58%-71%) in the IV protocol (P=0.36). Rescue procedures for persistence or recurrence of vasospasm, that is, mechanical angioplasty and/or IA milrinone infusion, were similar between the 2 protocols. Patients with a good neurological outcome at 1 year, that is, modified Rankin Scale scores 0-2, were comparable between the 2 protocols. Side effects of milrinone were uncommon and equally distributed within the 2 protocols. CONCLUSIONS These findings indicate that a continuous IV infusion of milrinone was as efficient as combined IA+IV infusion and suggest that this modality could be considered as a first easy-to-use option to treat patients with CVS.
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Gao Y, Zhuang Z, Lu Y, Tao T, Zhou Y, Liu G, Wang H, Zhang D, Wu L, Dai H, Li W, Hang C. Curcumin Mitigates Neuro-Inflammation by Modulating Microglia Polarization Through Inhibiting TLR4 Axis Signaling Pathway Following Experimental Subarachnoid Hemorrhage. Front Neurosci 2019; 13:1223. [PMID: 31803007 PMCID: PMC6872970 DOI: 10.3389/fnins.2019.01223] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/29/2019] [Indexed: 12/11/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) elicits destruction of neuronal cells and neurological function, which is exacerbated by neuro-inflammation in EBI, and toll-like receptor 4 (TLR4) plays an important role in inflammatory cascade via modulation microglia polarization. Curcumin (Cur), as a natural phytochemical compound, has the potential characteristics on anti-inflammatory and microglia phenotype transformation. In this study, we verified the hypothesis curcumin promotes M2 polarization to inhibiting neuro-inflammation, which through suppressing TLR4 signaling pathway after SAH. In tlr4–/– mice and wild type (WT) subjected to prechiasmatic cistern blood injection, Western blotting, brain water content, neurological score, enzyme-linked immunosorbent assay (ELISA) and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining were performed to investigate the role of TLR4 on neuro-inflammation response and microglia polarization. Curcumin with three different concentrations (50 mg/kg, 100 mg/kg and 200 mg/kg) were injected intraperitoneally (i.p.) at 15 min after SAH. The levels of TLR4, myeloid differentiation factor 88 (MyD88), nuclear factor- κB (NF-κB), Iba-1, CD86, CD206 and pro/anti-inflammation cytokines were measured by Western blotting and immunofluorescence staining at 24 h after SAH. SAH induction increased the protein levels of TLR4, pro-inflammation cytokines and proportion of M1 phenotype. Curcumin with 100 mg/kg treatment dramatically inhibited the release of pro-inflammatory mediators, and elevated the protein levels of anti-inflammatory cytokines and promoted microglia switch to M2. Meanwhile, curcumin treatment also decreased the expressions of TLR4, Myd88 and NF-κB at 24 h post SAH. TLR4 deficiency ameliorated brain water content, neurological deficit and reduced pro-inflammation cytokines after SAH. Moreover, curcumin treatment in tlr4–/– mice further induced M2 polarization, while had no statistic difference on brain water content and neurological score at 24 h post SAH. Our results indicated that curcumin treatment alleviated neuro-inflammation response through promoting microglia phenotype shift toward M2, and which might inhibiting TLR4/MyD88/NF-κB signaling pathway after SAH.
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Affiliation(s)
- YongYue Gao
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - Zong Zhuang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - Yue Lu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - Tao Tao
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Yan Zhou
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - GuangJie Liu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - Han Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Clinical Medical College of Southern Medical University, Guangzhou, China
| | - DingDing Zhang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - LingYun Wu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - HaiBin Dai
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - Wei Li
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
| | - ChunHua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital Nanjing University Medicine School, Nanjing, China
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Ayling OGS, Ibrahim GM, Alotaibi NM, Gooderham PA, Macdonald RL. Anemia After Aneurysmal Subarachnoid Hemorrhage Is Associated With Poor Outcome and Death. Stroke 2019; 49:1859-1865. [PMID: 29946013 DOI: 10.1161/strokeaha.117.020260] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Anemia after aneurysmal subarachnoid hemorrhage is common and potentially modifiable. Here, we first evaluate the effect of anemia on neurological outcome and death and second, study the effects of packed red blood cell transfusion on outcome. Methods- A secondary analysis on 413 subjects in the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage). Multivariable logistic regression identified independent risk factors for anemia and determined the effect of anemia on neurological outcome and death, while adjusting for selected covariates. Optimal predictive thresholds for hemoglobin levels were determined using receiver operating characteristic curve analysis. Finally, patients were pseudorandomized to transfusion using propensity score matching to study the effect of transfusions on outcome. Results- Anemia, defined as hemoglobin <10 g/dL, was present in 5% of patients at presentation, in 29% of patients after aneurysm securing (days 1-3), and in 32% of patients during the peak delayed cerebral ischemia risk period (days 5-9). Anemia after aneurysm securing (odds ratio, 1.96; 95% confidence interval, 1.07-3.59; P=0.03) and during the delayed cerebral ischemia window (odds ratio, 2.63; 95% confidence interval, 1.46-4.76; P=0.0014) was independently associated with poor neurological outcome. Anemia postaneurysm securing (odds ratio, 3.50; 95% confidence interval, 1.15-10.62; P=0.027) but not during the delayed cerebral ischemia window was associated with death. Using propensity score-matched cohorts, we found that transfusion of anemic patients did not improve long-term outcome (P=0.8) or mortality rates (P=0.9). Transfusion of patients with a hemoglobin concentration >10 g/dL was associated with improved neurological outcomes (odds ratio, 0.09; 95% confidence interval, 0.002-0.72; P=0.015), with no differences in mortality. Conclusions- Anemia after aneurysmal subarachnoid hemorrhage is associated with poor long-term neurological outcome and death. Transfusion of packed red blood cells is beneficial for patients who are not considerably anemic beforehand, suggesting further work needs to define the threshold but also the time period of anemia that is sufficient and necessary to contribute to poor outcomes. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00111085.
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Affiliation(s)
- Oliver G S Ayling
- From the Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G.)
| | | | - Naif M Alotaibi
- Department of Surgery, Li Ka Shing Knowledge Institute (N.M.A., R.L.M.).,Institute of Medical Science (N.M.A.), University of Toronto, Canada.,Division of Neurosurgery, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, St. Michael's Hospital, Toronto, Canada (N.M.A., R.L.M.)
| | - Peter A Gooderham
- From the Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G.)
| | - R Loch Macdonald
- Department of Surgery, Li Ka Shing Knowledge Institute (N.M.A., R.L.M.).,Division of Neurosurgery, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, St. Michael's Hospital, Toronto, Canada (N.M.A., R.L.M.)
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Mayer SA, Aldrich EF, Bruder N, Hmissi A, Macdonald RL, Viarasilpa T, Marr A, Roux S, Higashida RT. Thick and Diffuse Subarachnoid Blood as a Treatment Effect Modifier of Clazosentan After Subarachnoid Hemorrhage. Stroke 2019; 50:2738-2744. [PMID: 31394993 DOI: 10.1161/strokeaha.119.025682] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Clazosentan, an endothelin receptor antagonist, has been shown to reduce angiographic vasospasm and vasospasm-related morbidity after aneurysmal subarachnoid hemorrhage (SAH), although no effect on long-term functional outcome has been demonstrated. Thick clot on initial computed tomography is associated with an increased risk of vasospasm and delayed cerebral ischemia. In this post hoc analysis, we hypothesized that use of clazosentan in this subpopulation would provide stronger benefit. Methods- We analyzed SAH patients enrolled in the CONSCIOUS-2 and CONSCIOUS-3 studies (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) and compared the effects of clazosentan 5 mg/h, 15 mg/h, and placebo starting the day after aneurysm repair. The analysis was performed separately based on the presence or absence of thick (≥4 mm) and diffuse (≥3 cisterns) SAH on admission computed tomography. The primary composite end point was all-cause mortality and vasospasm-related morbidity at 6 weeks, and the main secondary end point was the extended Glasgow Outcome Scale at 3 months, adjusted for admission clinical grade. Results- Of 1718 randomized patients, 919 (53%) had thick and diffuse SAH. The primary composite end point in this group occurred in 36% of placebo-treated patients (n=294), 30% patients treated with clazosentan 5 mg/h (n=514; relative risk, 0.82; 95% CI, 0.67-0.99), and 19% patients treated with clazosentan 15 mg/h (n=111; relative risk, 0.54; 95% CI, 0.36-0.80). Despite this, death or poor functional outcome (Glasgow Outcome Scale ≤4) occurred in 33% of placebo-treated patients, 34% of patients treated with clazosentan 5 mg/h (relative risk 1.02; 95% CI, 0.84-1.23), and 35% of patients treated with clazosentan 15 mg/h (relative risk 1.14; 95% CI, 0.88-1.48). Conclusions- In an enriched population with thick and diffuse SAH, clazosentan at a dose of 5 and 15 mg/h was able to significantly reduce vasospasm-related morbidity in a dose-dependent manner. The absence of an effect on long-term functional status likely reflects the complexity and multiplicity of factors that contribute to poor outcome after SAH. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00558311; NCT00940095.
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Affiliation(s)
- Stephan A Mayer
- From the Department of Neurology, Henry Ford Hospital, Detroit, MI (S.A.M., T.V.)
| | | | - Nicolas Bruder
- Hopital de la Timone-Aix-Marseille Université, France (N.B.)
| | - Abdel Hmissi
- Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland (A.H., A.M., S.R.)
| | - R Loch Macdonald
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, ON, Canada (R.L.M.)
| | - Tanuwong Viarasilpa
- From the Department of Neurology, Henry Ford Hospital, Detroit, MI (S.A.M., T.V.).,Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand (T.V.)
| | - Angelina Marr
- Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland (A.H., A.M., S.R.)
| | - Sebastien Roux
- Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland (A.H., A.M., S.R.)
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The expression of cerebrospinal fluid exosomal miR-630 plays an important role in the dysfunction of endothelial cells after subarachnoid hemorrhage. Sci Rep 2019; 9:11510. [PMID: 31395931 PMCID: PMC6687820 DOI: 10.1038/s41598-019-48049-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/29/2019] [Indexed: 12/17/2022] Open
Abstract
The purpose of this study was to evaluate the relationship of brain microvascular endothelial cell (BMECs) function and the exosomal miR-630 expression after subarachnoid hemorrhage (SAH). We evaluated the effects of blood cerebrospinal fluid (BCSF) on proliferation of BMECs by MTT at 0, 1, 3, 7 and 12 days and performed cell cycle analysis after BCSF treatment for 48 h. The expression of endothelial adhesion molecules (ICAM-1, VCAM-1 and ZO-1) were detected by qRT-PCR and immunofluorescent staining after BCSF treatment. NO produced by BMECs was also evaluated by Griess assay. The expression of exosomal miR-630 was analyzed by qRT-PCR in BCSF treated cell cultu normal cell culture medium andre medium. We further compared the exosomal miR-630 of clinical patients between aSAH and normal hydrocephalus. The adhesion molecules expression was further detected after co-incubation with exosomes transfected by miR-630 mimics. We found that BCSF significantly reduced the cell vitality in a time-dependent manner (p < 0.05) and the growth inhibition ratio reached 78.34 ± 9.22% on the 12th day. BCSF induced cell cycle arrest in G0/G1 phase in BMECs (p < 0.01). The expression of ICAM-1, VCAM-1, ZO-1 and the NO produced by BMECs were markedly reduced following incubation with BCSF. Then we demonstrated that the expression of exosomal miR-630 was markedly reduced in the BCSF treated BMECs and the same phenomenon occurred in aSAH patients compared with normal hydrocephalus. The expression of ICAM-1, VCAM-1 and ZO-1 were then increased in BMECs cocultured with exosomes transfected by miR-630 mimics. In conclusion, the low expression of exosomal miR-630 in CSF was closely related to endothelial function in BCSF endothelial cell injury model and clinical patients.
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Lublinsky S, Major S, Kola V, Horst V, Santos E, Platz J, Sakowitz O, Scheel M, Dohmen C, Graf R, Vatter H, Wolf S, Vajkoczy P, Shelef I, Woitzik J, Martus P, Dreier JP, Friedman A. Early blood-brain barrier dysfunction predicts neurological outcome following aneurysmal subarachnoid hemorrhage. EBioMedicine 2019; 43:460-472. [PMID: 31162113 PMCID: PMC6558266 DOI: 10.1016/j.ebiom.2019.04.054] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/28/2019] [Accepted: 04/28/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Disease progression and delayed neurological complications are common after aneurysmal subarachnoid hemorrhage (aSAH). We explored the potential of quantitative blood-brain barrier (BBB) imaging to predict disease progression and neurological outcome. METHODS Data were collected as part of the Co-Operative Studies of Brain Injury Depolarizations (COSBID). We analyzed retrospectively, blinded and semi-automatically magnetic resonance images from 124 aSAH patients scanned at 4 time points (24-48 h, 6-8 days, 12-15 days and 6-12 months) after the initial hemorrhage. Volume of brain with apparent pathology and/or BBB dysfunction (BBBD), subarachnoid space and lateral ventricles were measured. Neurological status on admission was assessed using the World Federation of Neurosurgical Societies and Rosen-Macdonald scores. Outcome at ≥6 months was assessed using the extended Glasgow outcome scale and disease course (progressive or non-progressive based on imaging-detected loss of normal brain tissue in consecutive scans). Logistic regression was used to define biomarkers that best predict outcomes. Receiver operating characteristic analysis was performed to assess accuracy of outcome prediction models. FINDINGS In the present cohort, 63% of patients had progressive and 37% non-progressive disease course. Progressive course was associated with worse outcome at ≥6 months (sensitivity of 98% and specificity of 97%). Brain volume with BBBD was significantly larger in patients with progressive course already 24-48 h after admission (2.23 (1.23-3.17) folds, median with 95%CI), and persisted at all time points. The highest probability of a BBB-disrupted voxel to become pathological was found at a distance of ≤1 cm from the brain with apparent pathology (0·284 (0·122-0·594), p < 0·001, median with 95%CI). A multivariate logistic regression model revealed power for BBBD in combination with RMS at 24-48 h in predicting outcome (ROC area under the curve = 0·829, p < 0·001). INTERPRETATION We suggest that early identification of BBBD may serve as a key predictive biomarker for neurological outcome in aSAH. FUND: Dr. Dreier was supported by grants from the Deutsche Forschungsgemeinschaft (DFG) (DFG DR 323/5-1 and DFG DR 323/10-1), the Bundesministerium für Bildung und Forschung (BMBF) Center for Stroke Research Berlin 01 EO 0801 and FP7 no 602150 CENTER-TBI. Dr. Friedman was supported by grants from Israel Science Foundation and Canada Institute for Health Research (CIHR). Dr. Friedman was supported by grants from European Union's Seventh Framework Program (FP7/2007-2013; grant #602102).
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Affiliation(s)
- Svetlana Lublinsky
- Departments of Brain & Cognitive Sciences, Physiology & Cell Biology, Faculty of Health Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vasilis Kola
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Viktor Horst
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Germany
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | - Oliver Sakowitz
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Germany; Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Rudolf Graf
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ilan Shelef
- Departments of Brain & Cognitive Sciences, Physiology & Cell Biology, Faculty of Health Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Diagnostic Imaging, Soroka University Medical Center, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Johannes Woitzik
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Alon Friedman
- Departments of Brain & Cognitive Sciences, Physiology & Cell Biology, Faculty of Health Science, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Medical Neuroscience and Brain Repair Center, Dalhousie University, Halifax, Nova Scotia, Canada.
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Early serum miR-1297 is an indicator of poor neurological outcome in patients with aSAH. Biosci Rep 2018; 38:BSR20180646. [PMID: 30355655 PMCID: PMC6246762 DOI: 10.1042/bsr20180646] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 10/11/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022] Open
Abstract
Objective: MiRNAs are important regulators of translation and have been described as biomarkers of a number of cardiovascular diseases, including stroke. The purpose of the study was to determine expression levels of serum miR-1297 in patients with aneurysmal subarachnoid hemorrhage (aSAH), and to assess whether miR-1297 was the prognostic indicator of aSAH. Methods: We treated 128 aSAH patients with endovascular coiling. The World Federation of Neurological Surgeons (WFNS) grades, Hunt-Hess grades, and modified Fisher scores were used to assess aSAH severity. Neurologic outcome was assessed using the Modified Rankin Scale (mRS) at 1-year post-aSAH. Serum was taken at various time points (24, 72, and 168 h, and 14 days). Serum samples from aSAH patients and healthy controls were subjected to reverse transcription (RT) quantitative real-time PCR (RT-qPCR). Results: A poor outcome at 1 year was associated with significantly higher levels of miR-1297 value at the four time points, higher WFNS grade, higher Hunt-Hess grade, and higher Fisher score. Serum miR-1297 levels were significantly higher in patients, compared with healthy controls. There were significant correlations of miR-1297 concentrations in serum with severity in aSAH. The AUCs of miR-1297 at the four time points for distinguishing the aSAH patients from healthy controls were 0.80, 0.94, 0.77, and 0.59, respectively. After multivariate logistic regression analysis, only miR-1297 at 24 and 72 h enabled prediction of neurological outcome at 1 year. Conclusion: Serum was an independent predictive factor of poor outcome at 1 year following aSAH. This result supports the use of miR-1297 in aSAH to aid determination of prognosis.
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Persistent High Levels of miR-502-5p Are Associated with Poor Neurologic Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 116:e92-e99. [PMID: 29689401 DOI: 10.1016/j.wneu.2018.04.088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the temporal changes in miR-502-5p expression after aneurysmal subarachnoid hemorrhage (aSAH) and to find the time to peak level. METHODS We collected serum from patients with aSAH (n = 129) at various time points (1, 3, 7, and 14 days postevent) and healthy controls (n = 40) at the Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College, from May 1, 2015 to January 31, 2016. We measured expression levels of miR-502-5p by polymerase chain reaction. We used the 2-ΔCt method and calculated correlations among variables using Spearman rank correlation coefficient analysis. We used receiver operating characteristic curves to identify optimal levels of miR-502-5p for aSAH and multivariate logistic regression to analyze risk factors on the modified Rankin scale. We measured miR-502-5p expression at all 4 time points post-aSAH. RESULTS Levels rose moderately from day 1 to day 7, with a substantial decrease from day 7 to day 14. The peak was at day 7. Multivariate logistic regression revealed that higher miR-502-5p levels at 7 days were associated with a significantly high risk for poor outcome post-aSAH. CONCLUSIONS Our data suggest that persistent elevated levels of miR-502-5p participate in the development of aSAH and may help physicians to adjust therapy for aSAH.
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Mogollon JP, Smoll NR, Panwar R. Association Between Neurological Outcomes Related to Aneurysmal Subarachnoid Hemorrhage and Onsite Access to Neurointerventional Radiology. World Neurosurg 2018; 113:e29-e37. [PMID: 29410100 DOI: 10.1016/j.wneu.2018.01.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE An onsite access to neurointerventional radiology (NIR) may be useful for managing patients with aneurysmal subarachnoid hemorrhage (aSAH) after the aneurysm-securing procedure. We aimed to assess the association between neurological outcomes related to aSAH and onsite access to NIR service. METHODS This was a sequential period study of 47 patients with aSAH admitted consecutively during the pre-NIR period (January 2010 to June 2012) compared with 81 patients with aSAH admitted consecutively during the post-NIR period (January 2013 to June 2015) at an academic tertiary referral intensive care unit (ICU). The primary end point was the incidence of poor neurological outcome, defined as modified Rankin scale of ≥3 at 6 months from ictus. Secondary outcomes included incidence of symptomatic vasospasm (SV) and length of stay in ICU/hospital. RESULTS The primary end point was observed in 18 of 47 (38%) patients during the pre-NIR period versus 25 of 81 (31%) patients during the post-NIR period (P = 0.39). The post-NIR period did not have an independent impact on neurological outcomes (adjusted odds ratio = 0.8, 95% confidence interval 0.3-2.1; P = 0.66). Of the patients who developed SV, 10 of 47 (21%) were during the pre-NIR period versus 33 of 81 (41%) during the post-NIR period (P = 0.02). The post-NIR period and higher Fisher grade were independent predictors of SV. Patients with SV had similar outcomes, but with longer stay in ICU during the post-NIR period compared with the pre-NIR period. CONCLUSIONS Among patients with aSAH, the post-NIR period was associated with more frequent detection of SV, more endovascular procedures, longer hospital stay, but with no appreciable improvement in neurological outcomes either overall or in the subset of patients with SV. STUDY REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616000201471.
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MESH Headings
- Adult
- Aged
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Brain Damage, Chronic/epidemiology
- Brain Damage, Chronic/etiology
- Brain Damage, Chronic/prevention & control
- Computed Tomography Angiography
- Embolization, Therapeutic
- Endovascular Procedures/statistics & numerical data
- Female
- Humans
- Incidence
- Intensive Care Units/statistics & numerical data
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/surgery
- Intracranial Aneurysm/therapy
- Length of Stay/statistics & numerical data
- Ligation
- Male
- Middle Aged
- Radiography, Interventional/statistics & numerical data
- Recurrence
- Severity of Illness Index
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/epidemiology
- Subarachnoid Hemorrhage/etiology
- Subarachnoid Hemorrhage/surgery
- Tertiary Care Centers/statistics & numerical data
- Treatment Outcome
- Vasospasm, Intracranial/epidemiology
- Vasospasm, Intracranial/etiology
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Affiliation(s)
| | - Nicolas Roydon Smoll
- Melbourne School of Population Health, University of Melbourne, Melbourne, Australia
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
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Association of Perforator Infarction with Clinical Courses and Outcomes Following Surgical Clipping of Ruptured Anterior Communicating Artery Aneurysms. World Neurosurg 2017; 107:724-731. [DOI: 10.1016/j.wneu.2017.08.086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 11/23/2022]
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45
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Rinaldo L, Hughes JD, Rabinstein AA, Lanzino G. Effect of body mass index on outcome after aneurysmal subarachnoid hemorrhage treated with clipping versus coiling. J Neurosurg 2017; 129:658-669. [PMID: 29027862 DOI: 10.3171/2017.4.jns17557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It has been suggested that increased body mass index (BMI) may confer a protective effect on patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). Whether the modality of aneurysm occlusion influences the effect of BMI on patient outcomes is not well understood. The authors aimed to compare the effect of BMI on outcomes for patients with aSAH treated with surgical clipping versus endovascular coiling. METHODS The authors retrospectively reviewed the outcomes for patients admitted to their institution for the management of aSAH treated with either clipping or coiling. BMI at the time of admission was recorded and used to assign patients to a group according to low or high BMI. Cutoff values for BMI were determined by classification and regression tree analysis. Predictors of poor functional outcome (defined as modified Rankin Scale score > 2 measured ≥ 90 days after the ictus) and posttreatment cerebral hypodensities detected during admission were then determined separately for patients treated with clipping or coiling using stepwise multivariate logistic regression analysis. RESULTS Of the 469 patients admitted to the authors' institution with aSAH who met the study's inclusion criteria, 144 were treated with clipping and 325 were treated with coiling. In the clipping group, the frequency of poor functional outcome was higher in patients with BMI ≥ 32.3 kg/m2 (47.6% vs 19.0%; p = 0.007). In contrast, in the coiling group, patients with BMI ≥ 32.3 kg/m2 had a lower frequency of poor functional outcome at ≥ 90 days (5.8% vs 30.9%; p < 0.001). On multivariate analysis, high BMI was independently associated with an increased (OR 3.92, 95% CI 1.20-13.41; p = 0.024) and decreased (OR 0.13, 95% CI 0.03-0.40; p < 0.001) likelihood of poor functional outcome for patients treated with clipping and coiling, respectively. For patients in the surgical group, BMI ≥ 28.4 kg/m2 was independently associated with incidence of cerebral hypodensities during admission (OR 2.44, 95% CI 1.16-5.25; p = 0.018) on multivariate analysis. For patients treated with coiling, BMI ≥ 33.2 kg/m2 was independently associated with reduced odds of hypodensities (OR 0.45, 95% CI 0.21-0.89; p = 0.021). CONCLUSIONS The results of this study suggest that BMI may differentially affect functional outcomes after aSAH, depending on treatment modality. These findings may aid in treatment selection for patients with aSAH.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Departments of1Neurosurgery.,3Neurointerventional Radiology, Mayo Clinic, Rochester, Minnesota
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Sasaki K, Mutoh T, Nakamura K, Kojima I, Taki Y, Suarez JI, Ishikawa T. MRI-based in vivo assessment of early cerebral infarction in a mouse filament perforation model of subarachnoid hemorrhage. Neurosci Lett 2017; 653:173-176. [PMID: 28552456 DOI: 10.1016/j.neulet.2017.05.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/13/2017] [Accepted: 05/22/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Experimental subarachnoid hemorrhage (SAH) by endovascular filament perforation method is used widely in mice, but it sometimes present acute cerebral infarctions with varied magnitude and anatomical location. This study aimed to determine the prevalence and location of the acute ischemic injury in this experimental model. METHODS Male C57BL/6 mice were subjected to SAH by endovascular perforation. Distribution of SAH was defined by T2*-weighted images within 1h after SAH. Prevalence and location of acute infarction were assessed by diffusion-weighted MR images on day 1 after the induction. RESULTS Among 72 mice successfully acquired post-SAH MR images, 29 (40%) developed acute infarction. Location of the infarcts was classified into either single infarct (ipsilateral cortex, n=12; caudate putamen, n=3; hippocampus, n=1) or multiple lesions (cortex and caudate putamen, n=6; cortex and hippocampus, n=2; cortex, hippocampus and thalamus/hypothalamus, n=3; bilateral cortex, n=2). The mortality rate within 24h was significantly higher in mice with multiple infarcts than those with single lesion (30% versus 0%; P=0.03). Distribution of the ischemic lesion positively correlated with MRI-evidenced SAH grading (r2=0.31, P=0.0002). CONCLUSION Experimental SAH immediately after the vessel perforation can induce acute cerebral infarction in varying vascular territories, resulting in increased mortality. The present model may in part, help researchers to interpret the mechanism of clinically-evidenced early multiple combined infarction.
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Affiliation(s)
- Kazumasu Sasaki
- Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan; Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Tatsushi Mutoh
- Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan; Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
| | | | - Ikuho Kojima
- Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan; Department of Oral Diagnosis & Radiology, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Yasuyuki Taki
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Jose Ignacio Suarez
- Department of Neurology-Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA
| | - Tatsuya Ishikawa
- Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
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